Use of the CFIR in VA Implementation Research
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Use of the CFIR in VA Implementation
ResearchJulie C. Lowery, PhD, MHSA, Associate Director, CCMR; Co-Implementation
Research Coordinator, Diabetes QUERILaura Damschroder, MS, MPH, Co-
Implementation Research Coordinator, Diabetes QUERI
HSR&D Center for Clinical Management ResearchVA Ann Arbor Healthcare System
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Brief Description of VA’s QUERI Program CFIR Orientation Coding and Analysis Using the CFIR
MOVE! Study Tele-Retinal Screening Study
Next Steps/CFIR Wiki
(Focus on methods)
Outline
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Launched in 1998 “Using research evidence to improve
practice” Funded from medical care dollars (not
research) QUERI researchers employ concepts
from implementation science (aka knowledge utilization, knowledge translation, knowledge transfer)
Each QUERI is provided funds for an Implementation Research Coordinator (IRC)
VA’s QUERI: Quality Enhancement Research Initiative
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Chronic Heart Failure Diabetes eHealth HIV/Hepatitis Ischemic Heart Disease Mental Health Polytrauma and Blast-Related Injuries Spinal Cord Injury Stroke Substance Use Disorders
10 QUERI Centers
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To improve healthcare quality through the systematic implementation of research findings known to generate better outcomes than prevailing practices
#1 QUERI Goal
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Short turn-around time needed by operations
Establishing partnerships between researchers and managers
Who’s responsible for implementation—researchers or managers?
Different performance measures than in academics
Challenges for Researchers
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Primary aim: determine effectiveness of a clinical intervention
Clinical intervention: a specific clinical/therapeutic practice or delivery system/organizational arrangement or health promotion activity
Typical unit of randomization: patient or clinical unit
Summative outcomes: health outcomes, costs, process/quality measures (intermediate outcomes)
Clinical Effectiveness Trial
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Primary aim: determine utility of an implementation intervention/strategy
Implementation intervention: a method or technique to enhance adoption of a clinical intervention (e.g., electronic clinical reminder, audit/feedback, interactive education)
Typical unit of randomization: provider, clinical unit, or system
Summative outcomes: adoption/uptake of the clinical intervention; process measures/quality measures
Implementation Trial
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Combine features of both clinical effectiveness and implementation trials
Efficacy Studies Effectiveness Studies Implementation Research
Hybrid designs fall between effectiveness studies and implementation research
Hybrid Designs
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Primary aim: determine effectiveness of a clinical intervention
Secondary aim: better understand context for implementation
Hybrid Trial Type 1
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Coprimary aim: determine effectiveness of a clinical intervention
Coprimary aim: determine feasibility and potential utility of an implementation intervention /strategy
Hybrid Trial Type 2
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Primary aim: determine utility of an implementation intervention/strategy
Secondary aim: assess clinical outcomes associated with implementation trial
Hybrid Trial Type 3
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While there are multiple conceptual models to use for guidance, there is a need for research that identifies the determinants of field-level successes and failures
Conceptual Frameworks in Implementation Research
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Consolidated Framework for Implementation Research (CFIR)
A comprehensive framework to promote consistent use of constructs, terminology, and definitions Consolidate existing models and
frameworks Comprehensive in scope Tailor use to the setting
Damschroder L, Aron D, Keith R, Kirsh S, Alexander J, Lowery J: Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. 2009, 4:50.
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CFIR: 5 Major Domains Intervention
8 Constructs (e.g., evidence strength & quality, complexity) Outer Setting
4 Constructs (e.g., patient needs & resources) Inner Setting
14 constructs (e.g., leadership engagement, available resources)
Individuals Involved 5 Constructs (e.g., knowledge, self-efficacy)
Process 8 Constructs (e.g., plan, engage, champions)
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The CFIR: Embraces, consolidates, and
standardizes key constructs from other models
Agnostic to specific models and theories Provides a pragmatic structure for
evaluating complex implementations Helps to organize findings across
disparate implementations Paves the way for cross-study synthesis
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Application of the CFIR Consists of 39 individual constructs Cannot use them all in every study
And not all will apply A priori assessment of which constructs to
include Modifiable & non-modifiable constructs
Determine levels at which each construct may apply E.g., teams, departments, clinics, regions
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MOVE! weight management program disseminated in 2006
Objective: Identify differences in organizational factors between facilities with high MOVE! implementation effectiveness versus those with low implementation effectiveness Help explain the high variation in levels of
patient participation observed across VHA facilities
MOVE! Study
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Purposive sample of 5 low & high uptake sites
Semi-structured interviews with 24 key stakeholders 83% of those contacted and invited participated
Qualitative analysis Deductive, using CFIR Inductive, open to new themes Team-based analysis
Methods
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Interview key stakeholders to identify CFIR constructs that they think are most important for predicting implementation success
Develop interview guide based on these constructs
Use of CFIR for Data Collection
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Team-based AnalysisTranscriptsTranscriptsTranscripts Assign
transcripts to pairs of analysts
Develop Initial Case MemoCFIR Initial
Case Memo
InterviewTranscripts
Other Themes
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Analyze by case (site) For each transcript:
Each analyst independently codes Meet to compare and achieve consensus on
coding Work together to develop summary
statements with supporting quotes By construct
Develop initial case memo
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2 pairs of analysts + PI + implementation researcher (+ qualitative expert)
Pairs of analysts present their “initial case memos” Accept, merge, modify statements Write new statements
Finalize group memo
Large Group Consensus
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Team-based Analysis
Repe
at fo
r ea
ch c
ase
TranscriptsTranscriptsTranscripts Assign transcripts to
pairs of analysts
Develop Initial Case MemoCFIR Initial
Case Memo
InterviewTranscripts
Other ThemesLarge Group Consensus
Modify Memos(+Quotes)
Group ConsensusMemo
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Think of CFIR constructs as independent variables Construct1 + construct2 + … =
f(implementation effectiveness) Ratings ordinal values of independent
variables Is the construct positive or negative
force in the organization? Does it manifest strongly or weakly? Is the construct present but neutral?
Rating Constructs
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Weak General statements No direct, concrete examples
Strong Specific statements Direct, concrete examples
Neither Neutral
Mixed effects balancing to neutral Present but no effect
Missing: Unaware, not sufficiently knowledgeable
Assign Construct Strength
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Rate constructs within each case Compare constructs across cases Identify constructs that correlate with
implementation success
Rating Constructs
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See handout
Rating Matrix
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Review qualitative data for operationalization of key constructs at sites with high implementation effectiveness, and review barriers at sites with low implementation effectiveness
Recommendations
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Lack of blinding
Study Limitation
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Objective: to identify factors associated with the variability in uptake of VA tele-retinal imaging program across networks (VISNs)
Characterized low and high uptake sites based on reach
9 VISNs 42 interviews
Tele-retinal Screening Study
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7 of 39 CFIR constructs rated negative or neutral in VISNs with low screening rates and rated more positively in VISNs with high screening rates: External policies and incentives Networks and communications Organizational incentives and rewards Learning climate Access to knowledge and information Personal attributes Primary care engagement
Tele-retinal Screening Study:Results
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Increase efficiency of process Use validated surveys to measure CFIR
constructs Determine correlation between constructs
and implementation effectiveness Focus qualitative data collection on highly
correlated constructs
Next Steps
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The CFIR Wiki The CFIR Wiki will promote:
Shared definitions Operationalization of definitions Repository of findings Predictive modeling Site-specific “System-change likelihood
Indices”1
Which will result in… … more reliable implementation strategies …more generalized knowledge about what
works where and why1. Davidoff F: Heterogeneity is not always noise: lessons from improvement. JAMA 2009, 302:2580-2586.